Medicare Risk-Adjustment Coding Auditor

Sanford; United States; On-site; USD 30,000 - 48,000; Full time

Job summary

Sanford Health in the United States is seeking a Coding Audit Specialist to conduct quality assurance of risk adjustment data for CMS and DHS. You will audit medical records, ensure diagnostic codes meet CPT/ICD-9/ICD-10 guidelines, and support revenue management across Medicare Advantage, ACA/Exchange, and BadgerCare Plus programs.

Responsibilities include developing monitoring programs for risk scores, identifying coding deficiencies, and presenting clear audit outcomes to leadership.

Qualifications

• High school diploma or equivalent required. Demonstrated knowledge of anatomy/physiology and medical terminology. Completion of courses in Current Procedural Terminology and , ICD-9 and ICD-10 coding required.
• Associate Degree in coding and/or health-related field preferred.
• Three years of experience required in a health insurance, compliance, quality assurance, or auditing related position. Experience with ICD-9, ICD-10, CPT, HCC and HCPCS coding. Knowledge of the different CMS guidelines that affect Medicare Advantage, HHS-ACA and DHS/BadgerCare Plus members as related to revenue management.
• Demonstrated knowledge of Word, Excel, and Access.
• Certified Professional Coder and/or Certified Risk Adjustment Coder certification awarded by American Academy of Professional Coders required within one year of hire.

Responsibilities

• Develops, implements and monitors, along with risk adjustment leadership, to provide a continuous monitoring program for Medicare Advantage risk adjustment scores, ACA/Exchange and Medicaid/BadgerCare Plus member diagnosis documentation.
• Audits medical record documentation to ensure correct codes have been selected and to detect un-coded or miscoded diagnoses for the Medicare Advantage, ACA/Exchange and BadgerCare Plus member populations.
• Develops and maintains the skills necessary to accurately audit the coding for visits (evaluation and management) and procedures documented by physicians, hospitals and other providers in the various specialties and subspecialties as it relates to HCC coding.
• Maintains knowledge of CPT coding rules, ICD-9 and ICD-10 codes, HCPCS codes, HCC coding, use of modifiers, documentation guidelines, CMS Policy requirements, and other reimbursement guidelines to ensure accurate documentation review and diagnosis code assignment.

Skills

Anatomy/physiology

Medical terminology

CPT ICD coding knowledge

Audit/quality assurance

CMS guidelines awareness

Education

High school diploma or equivalent

Associate Degree in coding/health-related field (preferred)

Tools

Word

Excel

Access

Job description

Sanford Health in the United States is seeking a Coding Audit Specialist to conduct quality assurance of risk adjustment data for CMS and DHS. You will audit medical records, ensure diagnostic codes meet CPT/ICD-9/ICD-10 guidelines, and support revenue management across Medicare Advantage, ACA/Exchange, and BadgerCare Plus programs.

Responsibilities include developing monitoring programs for risk scores, identifying coding deficiencies, and presenting clear audit outcomes to leadership.